Service Recipient Paperwork

Service Recipient Paperwork
Important:

If you are completing this form on behalf of the Service Recipient, you MUST be the Service Recipient's legal Power of Attorney, and you must provide the Power of Attorney documentation.

Service Recipient Information and Assessment
Name of Service Recipient*

First NameLast Name
SSN#*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Admission/Services Began*

MonthDayYear
Date
Sex*
Date of Birth*
Referred by
Emergency Contacts
Emergency Contact #1*
Emergency Contact #2*
Emergency Contact #3
Medical History
*
*
*
Check all that apply
Chronic Illnesses:*
Acute Conditions:
Describe above conditions*
Surgeries*
Check all that apply*
Describe above conditions*
Please list all medications and dosages
Have you been vaccinated for COVID-19?*

YesNo
Insurance Coverage*
Medicare Number (If Applicable)
Check all the apply*
Assessment of Needs
Describe other history, habits, behaviors, etc.*
List likes and dislikes*
Source of Financial Support/Financial Arrangements
Is service recipient responsible for payment of services?*

YesNo
If the service recipient does not manage his/her own finances, list the name of the person/agency responsible for payment of services*
Legal Documents
Is the service recipient legally competent?*

YesNo
Please provide the following documents if available
Durable Power of Attorney

Browse Files

Cancelof
Living Will

Browse Files

Cancelof
DNR-Do Not Resuscitate

Browse Files

Cancelof
Service Recipient Rights, Confidentiality, Responsibilities, and Grievance Procedures
Rights and Confidentiality:
- to be treated with consideration, respect, and full recognition of their dignity and individuality, and have courteous, compassionate care
- to be protected by the licensee from neglect, physical, verbal and emotional abuse (including corporal punishment), and from all forms of misappropriation and/or exploitation
- to have reasonable personal privacy when recieving care
- to be informed about care and to be involved in care planning
- to submit complaints without fear of retaliation and have them addressed timely
- to refuse services and be informed of the impact toward your care
- to be informed of any changes in care, including the type, amount, and frequency
- to participate fully, or to refuse to participate, in community activities
- not to be required to make public statements which acknownledge gratitude of the agency
- identifiable photographs will not be used without written and signed consent by the service recipient or guardian
- to voice grievances to the licensee and to outside representatives of their choice with freedom from restraint, interference, coercion, discrimination or reprisal
- to be assisted in the exercise of civil rights
Responsibilites:
- to promptly inform care provider if service recipient will be away from home when services are scheduled
- to report any changes in your health or living conditions which concern service recipient's care
- to cooperate with care providers and ask questions to better understand
- to provide a safe home environment so that services can be safely provided
Grievance Procedures:

You have the right to voice grievances to the staff of the agency, to the owner of the agency, and to outside representatives of your choice with freedom from intereference, coercion, discrimination, or reprisal.

Any questions or specific concerns regarding service recipient's rights or to report a complaint may be directed to the following:
- Your Personal Support Service Agency (256) 619-0144
- TN State Office of Licensure & Review 1-866-777-1250
- Disability Law and Advocacy Canter of TN 1-800-342-1660
- TN Department of Human Services-Adult Protection Services 1-888-277-8366
Below is a copy of Service Recipient Rights, Confidentiality, Responsibilities, and Grievance Procedures. Please print this off to have a copy of this document.
I have been explained and received a copy of Service Recipient Rights, Confidentiality, Responsibilities, and Grievance Procedures.
Service Recipient or Guardian's Signature
Date

MonthDayYear
Date
Dear Personal Support Services Participant:
It is the policy of the Personal Support Services agency that a criminal history background check be done for all people who provide direct care or have direct contact with elderly or disabled people in their home. Prestige Homecare will make sure a background check has been completed on each employee before he/she comes to your house to help you.

Our agency is required to provide training annually to our employees so you can be assured that they can perform their duties. Our employees have promised to foster respect, dignity, privacy, and confidentiality for the people that we serve. This includes allowing people to decide whether to be a part of a program or activity.

Our employees must cooperate with any other service providers and provide services in an efficient, cost effective manner. Also, our employees must not improperly attempt to gain any money or goods from any participant or their family.

If you have any questions or problems with anyone coming to your home to provide home and community based services, please call Prestige Homecare, LLC at (256) 619-0144
Service Recipient or Guardian's Signature
Date

MonthDayYear
Date
Prestige Homecare Service Recipient Policy & Procedures
Below is Prestige Homecare's Service Recipient Policy & Procedures. Please read and print off your own copy.
I have read and understand Prestige Homecare's Policy & Procedures. I agree to follow Prestige's guidelines to the best of my ability.
Signature*

Clear
Date*

MonthDayYear
Date

Medication Assistance Authorization
I authorize Prestige Homecare, LLC to provide medication assistance as designated by the agreed Service Plan. Medication assistance includes, but is not limited to, any of the following:
- loosening the cap on a pill bottle for oral medication
- opening a pill reminder box if the box is filled by the service recipient or authorized representative or licensed medical personnel practicing within the scope of their license
- placing medication within reach of the service recipient
- holding a service recipient's hand steady to help them with drinking liquid medication
- guiding the service recipient's hand when the individual is applying eye/ear/nose drops and wiping excess liquid
- helping with a nasal cannula or mark for oxygen, plugging the machine in and turning it on
- applying non-prescription creams and lotions purchased over-the-counter to external parts of the body
I understand that I must notify the agency of any changes in the medication
Service Recipient or Guardian's Signature
Date

MonthDayYear
Date
CONSUMER NOTICE
TO: SERVICE RECIPIENT NAME
Thank you for your trust in allowing us to provide services in your home. Before we begin services, we wanted you to know the following about our operations:

1. All of our caretakers are supervised daily by reporting to our office before and after they provide your services.

2. We assign duties to the caretaker based on the services you need (or as directed by your payer).

3. We require the following of each caretaker we hire. If they do not meet these requirements, we have policies on discipline or firing to follow:
A. Must pass a criminal background check
B. Must receive positive references from the majority of individuals they’ve given us to contact
C.Must have appropriate credentials, licensure or certification (if required) and adequate training to provide services to you.

4.We provide each of our caretakers with the following:
A.Identification as one of our caretakers
B. Materials or equipment they need to provide your services (i.e., cleaning supplieS, Hoyer lift, gait belt, etc. C. Payroll, taxes, social security, workers’ compensation insurance; unemployment compensation payments, and overtime pay for hours worked in excess of 40 hours a week. This assures that you have no liability for the taxes of our caretakers (as you would if you hired them directly).

We would appreciate your signature below signifying that you have been advised of our company’s policies. Again, thank you for your confidence and should you have any issues during the course of your services, please call:

Cheryl Smith (256)619-0144
Signature*

Clear
Date*

MonthDayYear
Date

CONFIDENTIALITY AND NON-SOLICITATION AGREEMENT FOR SERVICE RECIPIENTS

In consideration of my professional affiliation with Prestige Homecare, LLC (“Prestige”) and/or its affiliates or successors, I agree as follows:

Confidential Informational

I acknowledge that Confidential Information may be made available to me and/or developed by me during my affiliation with Prestige.
Confidential Information consists of all information belonging to Prestige that has been identified as confidential. Confidential Information includes, but is not limited to, hourly fee rates, proprietary information of Prestige,etc., and information related to Presitge’s employees and/or caregivers.
I acknowledge that as a result of my affiliation, a duty has been imposed on me to not use Prestige’s Confidential Information on my or another party’s behalf and/or personal, financial, or professional gain.

Non-Solicitation of Caregivers

For a period of twelve months after the date of termination of my services from Prestige for any reason, I agree that I will not, directly or indirectly, hire, attempt to hire, solicit for employment or encourage the departure of any employee of Prestige, to leave employment with Prestige.
Signature*
Date*

MonthDayYear
Date

Personal Support Services Fee Agreement

Please read and complete the following document.
Agency: Prestige Homecare, LLC
The rate for providing services is $ * per hour.
The rate for overnight services is $ * per hour at night.
The services will be provided at a minimum of 40 hours per week (unless otherwise decided) , and will not exceed 168 hours per week.

Services will terminate if an invoice is not paid by the date it is due.

A Service Recipient may cancel services at any time with a written 30 day notice of the intended cancellation date.

I understand and accept the terms of this agreement for the services to be provided as determined in the "Service Care Plan"
Service Recipient/Authorized Representative Signature*
Date*

MonthDayYear
Date

By signing, I agree that I have read and agree to the Terms & Conditions*
Should be Empty:

Service Recipient Paperwork

Service Recipient Information and Assessment

Service Recipient Rights, Confidentiality, Responsibilities, and Grievance Procedures

Dear Personal Support Services Participant:

Prestige Homecare Service Recipient Policy & Procedures

Medication Assistance Authorization

CONSUMER NOTICE

Personal Support Services Fee Agreement